Structural stigma and intersectional inequality in schizophrenia: A systematic review and qualitative meta-synthesis

Schizophrenia is unequally distributed across social hierarchies and is associated with stratified pathways of care, coercion, and recovery. Although stigma has been widely studied, existing scholarship has predominantly emphasized interpersonal attitudes and individual behavior, leaving structural stigma embedded in policy regimes, institutional practices, and epistemic hierarchies insufficiently synthesized. Guided by PRISMA 2020, this systematic review and qualitative meta-synthesis examined 29 sources, comprising 17 core empirical studies and 12 contextual or theoretical sources, addressing schizophrenia or psychosis in relation to at least one additional marginalized social position. Five overlapping structural mechanisms were identified: economic/policy exclusion; spatial/environmental marginalization; institutional care inequities/cultural unsafety; coercive/carceral pathways; and epistemic injustice/diagnostic bias. Across settings, these mechanisms interacted to shape access to services, pathways into care, the credibility accorded to lived experience, autonomy, and opportunities for recovery. Their effects were most pronounced where schizophrenia-related stigma intersected with racialization, socioeconomic disadvantage, migration status, homelessness, sexual or gender minority status, Indigenous identity, criminal justice involvement, or HIV-related vulnerability. The findings support conceptualizing structural stigma as an upstream determinant of inequality in schizophrenia, operating through both material resource allocation and symbolic recognition within mental health systems. Reducing these inequalities requires coordinated, intersectionality-informed reform across policy, institutional, community, and epistemic domains rather than relying solely on individual-level interventions.